However, a great deal will depend on the terms of reference of the Royal Commission. I have been practising as a specialist geriatrician for 45 years. Throughout that time and up to last week, I have undertaken home visits and visited residents in aged care facilities. I treat all patients identically, irrespective of the setting, at hospitals, clinics, private rooms, homes and residential facilities.

Throughout that time, I have participated in and contributed to numerous high level enquiries at federal, state, regional and local level. All begin with assumptions and a starting position and methodology that often leads to what amounts to tinkering with the status quo rather than major change. Royal Commissions take a very long time.

In Australia, governments deal with difficult social problems by creating amorphous groups, such as “the aged” and “the disabled”, or equally amorphous issues, such as “aged care” and “mental health”, ostensibly to give them special attention oversight by a Minister.

This results in the creation of minority groups that are vulnerable to discrimination and exploitation. The special group’s access to mainstream services and institutions is then only through “special services”, which act as a barrier when they should have the same access as any other citizen.

A major complication in this case is that residential facilities are outside the state health services arena, and services emanating from state hospitals, clinics, and community health services do not extend to residential facilities at all. State-employed geriatricians and psychiatrists do not visit residential facilities as part of their service obligation (not that home visiting is particularly common in this day and age), whereas they would visit state-run long-term care facilities as a matter of course.

We seem to accept that aged care in its entirety is the rightful domain of the aged care industry (the starting position), even though entry into high level residential care is limited to people with enough physical, cognitive and mental impairment and disability to warrant this level of care.

I contend that high level care is a level of health care. It is not an accommodation option that anyone can choose as a lifestyle. It is long term, continuing and palliative health care. The qualifications of carers and the carer time that it takes to provide this level of care is obvious and predictable.

High level care is the most complex and demanding level of long-term and continuing care. It is not passive warehousing. It must actively include prevention, treatment, rehabilitation and palliative care.

The gross failure of the system and the incapacity of the aged care industry to provide an even remotely adequate level of continuing and palliative care has resulted in all the horrendous instances of personal abuse and mismanagement that the Four Corners episodes have brought to public attention. The current providers of aged care may be able to run a hotel, but they are completely unable to run a hospital.

If Oakden nursing home in South Australia had been a mental health unit, as the sign over the front door implied (“Mental health services for older persons”) and had faced health unit accreditation, and if the Mental Health Service had met its ethical and legal obligations regarding duty of care, we would never have heard of Oakden.

But wait.

Long before Oakden there were long-stay facilities managed by the state’s mental health service. They were called Makk House and McLeay House, and they provided a valuable service in dealing with behaviourally disturbed and difficult to place people. They were fully staffed by trained nurses, medical officers, and psychiatrists. For purely financial reasons (Commonwealth government funding), they became the Makk and McLeay Nursing Home at Oakden. The rest, as they say, is history.

Just as Oakden had a capable and effective ancestor, so did general long-term care. In the 1970s, I was the visiting specialist responsible for half of the long-stay wards of the Royal Adelaide Hospital at the Hampstead Centre. Again, they were properly staffed with access to all necessary specialist nursing and allied health professional expertise. The funding was from the state budget.

In the 1990s and early 2000s, the network of domiciliary care and rehabilitation services that covered the whole metropolitan area of Adelaide and had outreach into rural and remote communities provided a very comprehensive home-based service for many thousands of people that makes My Aged Care look like amateur hour. They did not survive a series of very expensive reforms.

Perhaps the saddest thing about this tragedy is that relatives have had to endure the anguish of finding out that the people, to whom they had entrusted the care of helpless people that they loved, had perpetrated callous abuse on them. They discovered this through very indirect means and had enormous difficulty having their concerns heard by anyone in authority. The Four Corners exposé will have raised alarm in other unsuspecting and already guilty relatives because “they put mother in a nursing home”.

Many of these relatives were legally substitute decision makers, who were not only entitled to information but should have been consulted when any significant care decision was made, and they had the right to agree or disagree to any proposed action. They were also advocates for and defenders of the rights of their relative. Any standards accreditation should ensure that facilities understand this point and demonstrate that they are complying with this, one of the most important standards.

All of the high level enquiries and undertakings that followed the Oakden disaster have resulted in no significant change. It will be business as usual, just with more rigorous standards assessment and a few more hours of clinical time.

I will end on a positive note.

Most of the facilities that I visit provide good quality care because the nurses, allied health professionals, and base-grade carers are decent dedicated people. Most of my working life is in rural and remote South Australia. The quality of residential care in rural towns is very much better, in every way, than in the metropolitan area. Country towns have true community spirit. An old person admitted to the local aged care facility has a history and understanding in that community, they may have been a teacher, a friend’s parent, the person who delivered Meals on Wheels. The people working in the facility in all capacities are mostly local people. The GP that was looking after them in the community and looked after them at the local hospital will continue to look after them at the nursing home. That GP will treat them with the same care and respect that they always have. The practice cared for them when they were born, and will continue to care for them as they die. Perpetrators of poor standards or abuse would be answerable to the whole town.

I can confidently counsel partners and relatives that when somebody needs 24-hour care, entry into high level care is not an abandonment nor a condemnation to a living hell.

I could go on and on. Anyone interested in greater detail can find it in my book, Dementia is different, available through my website.

Dr Ludomyr Mykyta, AM, is a consultant geriatrician based in South Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.

7 thoughts on “Aged care: a geriatrician’s view”

Dr Mykyta raises a number of important points. As a health researcher and primary carer for a relative with dementia, I am constantly battling My Aged Care and the barriers that they have to accessing services that would allow the relative to stay at home. It makes no sense either from a health perspective or economically and that’s before we even consider the patient’s wishes.

Excellent and accurate perspective. Abandonment of so many patients in aged care and chronic mental health is a consequence of economic liberalization policies such as privatization, austerity, and deregulation. This simply does not work where you have very vulnerable and dis-empowered “clients” or “consumers”, such as in these patient groups. What we are witnessing is a reminder that Neoliberalism is a often a problem for society although great for capitalists who have the ear of government. As Dr Mykyta has observed, in rural communities the Keynesian concept of community consensus has provided some protection from the changes of the 2000’s. Interesting to see how a Royal Commission will address this.

I worked as an aged carer during medical school and then and in my 10+ years in tertiary centres, the biggest problem by far that I have seen with our health system is a failure to recognise and treat dementia as a terminal illness. Statins and antihypertensives are continued at baseline. Once the patient presents to hospital they are poked and prodded, IV fluids are given for poor oral intake (poor because their brain is so deteriorated it has lost the will to drink), and infections are treated so the bed-bound, non-communicative, doubly incontinent person can be sent back to their nursing home bed. We would never do that to a young mentally capable person with cancer. I would never want that for myself or a loved one. We need to educate families and medical staff that dementia is a terminal illness and develop pathways to prevent unecessary and harmful hospital presentations, admissions and treatments, and to ensure dignity and comfort are maintained. Not only would this be in the best interests of our elderly, and ourselves as we face old age, but would also ease a huge burden on a health system bursting at the seams, which I believe would help improve the quality of care that is generally delivered in our hospitals.

When my mother was in aged care( at 98), a nurse gave her endone, after a fall, when her record clearly stated that she was sensitive to it, having had an acute confusional state previously. It took 4 days for the confusion to clear. When I attempted to complain about it, all I had was complete denial that there was a problem and the nurse had been within her professional boundaries, so I took it to the ombudsman who said it was outside their jurisdiction.
I was astonished, not even a sorry.

This is a very insightful and interesting commentary. I really appreciate that Dr Mykyta has highlighted the significant care needs of the persons who require high level aged care and and skills and resources needed to be able to appropriately provide for these needs. Many of the people working in aged care are carrying out an extremely difficult and demanding job on a day to day basis often with minimal training, little gratitude or understanding and very minimal financial reward. This provides no excuse for abusive behaviour, but we must consider that providing better funding for training and support of staff would likely translate to better care of our friends and family residing in aged care facilities.

Thank you Lu Mykyta. I remember you well from my many years in SA Health. and couldn’t agree more. The points you raise about a fragmented system largely driven by funding arrangements are absolutely correct and this structure significantly impedes any chance we have of developing an integrated health system . If you read the Productivity Commission Report 2017, it states we’ve achieved very little in the past 19 years!

I have also heard claims that a strategy in response to the Royal Commission should include the requirement for a Registered Nurse on every shift. Many years ago, I also worked as a RN in aged care (casually). I was an single RN on a shift – 60 residents; many with private rooms. The other staff were minimally trained carers. My shift was spent predominantly doing medication rounds with little opportunity to supervise other staff, and to really provide what i considered to be good safe, quality care and to when it was needed – to sit and hold someone’s hand.

My concern is that we might once again jump to band aid solutions that fail to really drive the change that’s needed.